A 79-year-old woman presented with a one-day history of acute onset of right upper abdominal pain. Nausea, and vomiting were also present. The vital signs were normal. Examination revealed a very tender mass in the right upper quadrant of abdomen. Laboratory investigations, including complete blood cell count, and liver function tests were within normal limits.
Abdominal ultrasound (US) examination showed a distended gallbladder, thickened gallbladder wall and fluid collection around the gallbladder. Ultrasonographic Murphy's sign was positive.
No stones were detected by US. Computed tomography (CT) of the abdomen showed that the gallbladder was not within the normal anatomical liver fossa. The wall was thickened, and at one point the integrity of the wall was lost. Fluid collection all around the gallbladder indicated a "floating gallbladder" and well-enhanced curvilinear structure on the right side of the gallbladder indicating cystic duct were also identified. Diffuse edematous smooth thickening of the gastric antral wall was observed which was compatible with secondary inflammation (Figure and ). There were no calculi in biliary system.
Figure 1 Contrast enhanced computed tomographic images show; loss of integrity of gallbladder wall (arrows). Diffuse thickening of the gastric antral wall (thin arrows). (b) CT image obtained upper level showed fluid collection (arrows) and well-enhanced curvilinear (more ...)
The patient underwent laparotomy with a preoperative diagnosis of acalculous cholecystitis with possible gangrene. At laparotomy, the gallbladder was distended, and multiple necrotic areas were observed. It was rotated more than 180 degrees clockwise around its mesentery, and there were no gallstone in gallbladder (Figure ). Cholecystectomy was performed in standard fashion. Histopatology of gallbladder was reported as hemorhagic transmural necrosis. The patient was discharged on second postoperative day.
The gallbladder was rotated more than 180 degrees clockwise around its mesentery. GB: gallbladder, CD: cystic duct, CA: cystic artery.